NTSB/RAB-14/12

National Transportation Safety Board

Railroad Accident Brief

Metro-North Railroad Derailment

Accident No.: DCA14MR003

Location: Bronx, New York

Date: December 1, 2013

Time: 7:19 a.m. eastern standard time

Railroad: Metro-North Railroad

Property damage: $9 million

Injuries: 61

Fatalities: 4

Type of accident: Derailment

The Accident

On Sunday, December 1, 2013, at 7:19 a.m. eastern standard time, southbound

Metro-North Railroad (Metro-North) passenger train 8808 derailed at milepost 11.35 on main

track 2 of the Metro-North Hudson Line.1 The train originated in Poughkeepsie, New York, with

a destination of Grand Central Station in New York, New York. The train consisted of

seven passenger cars and one locomotive; the locomotive was at the rear of the train in a push

configuration. All passenger cars and the locomotive derailed. The derailment occurred in a 6°

left-hand curve where the maximum authorized speed was 30 mph. The train was traveling at

82 mph when it derailed. As a result of the derailment, 4 people died and at least 61 persons were

injured. Metro-North estimated about 115 passengers were on the train at the time of the

derailment.

Metro-North estimated damages at more than $9 million. At the time of the accident, the

weather was 39°F, cloudy skies, and clear visibility.

Brief Narrative

The Metro-North crew reported for duty at Poughkeepsie at 5:04 a.m. The crew took

charge of train 8808 and departed Poughkeepsie en route to Grand Central Station. The train

made its first stop at New Hamburg, and then made eight additional stops prior to the derailment.

Train 8808 made its last stop at Tarrytown, New York, which is about 14 miles north of the

accident site.

1 All times in this brief are eastern standard time.

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Upon passing Riverdale, about 2 1/2 miles north of the accident site, the engineer

increased the train speed to 70 mph. The engineer maintained full throttle, and the train speed

increased to 82 mph. As the train entered a 30-mph curve at milepost 11.4, the train derailed.

During the derailment sequence many of the cars slid on their right sides in the direction of

travel, and window glazing (panes) detached from the cars. Based on the locations of the

four passengers who died at the end of the accident sequence, the extent of dirt and plant material

in wounds and the nature of their injuries, all four were completely or partially ejected from the

train through window openings. In addition, two of the seriously injured passengers sustained

severe injuries consistent with contacting the ground outside the train as the cars slid along the

ballast.

The engineer later told investigators that he remembered feeling “dazed” or “hypnotized”

just before the derailment. The train brakes were not applied before the derailment.

Figure 1. Accident scene.

The investigation determined that the following were not factors in the accident: signal

system defects; the track condition; the train’s mechanical condition; and the actions of the

Metro-North rail traffic controller.

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Engineer Medical Condition

Metro-North medical records indicate that the engineer had passed all required physical

examinations. The engineer’s personal medical records indicate that he had complained of

fatigue prior to the accident and had been diagnosed with low testosterone and later

hypothyroidism. He was obese with a body mass index of 36.4 in the week following the

accident.2 During interviews following the accident, the engineer reported that his wife had

complained of his snoring.

After the accident, the engineer had a sleep evaluation that identified excessive daytime

sleepiness and underwent a sleep study that resulted in a diagnosis of severe obstructive sleep

apnea (OSA). The engineer had multiple OSA risk factors, including obesity, male gender,

snoring, complaints of fatigue, and excessive daytime sleepiness. Although the engineer had

these multiple risk factors and multiple visits with health care providers, neither his personal

medical providers nor his occupational health evaluations by Metro-North identified his OSA.

Following the sleep study, successful treatment of the engineer’s OSA was accomplished

within 30 days of the diagnosis.

The Metro-North medical protocols and the Federal Railroad Administration (FRA)

regulations in place at the time of the accident required triennial vision and hearing testing but

did not require screening safety sensitive personnel for sleep disorders or any other medical

conditions.3

Engineer Work Shift Change

Beginning on November 18, 2013, less than 2 weeks before the accident, the engineer’s

work schedule changed dramatically as a result of a routine job bid process, called the “pick.”4

After more than 2 years working shifts beginning in the late afternoon or evening and ending in

the early morning, the engineer began to work shifts that that began in the dark of early morning

(4-5 a.m.) and continued until early afternoon. Adjusting to a new wake/sleep schedule can take

days or longer, depending on the difference between the previous and current schedules and the

quality of restorative sleep obtained. The engineer told investigators that on his new work

schedule he began to awaken around 3:30 a.m. and retire between 8:00 p.m. and 8:30 p.m. His

wake/sleep cycle had now shifted about 12 hours. The engineer reported that his wake and sleep

times varied in the days preceding the accident around the Thanksgiving holiday, which could

have degraded his quality and quantity of sleep. Given the substantial shift in work schedules and

the varied sleep/wake times, it is likely that the engineer had not adjusted fully to the new work

schedule at the time of the accident. The engineer’s OSA combined with his incomplete

2 Body mass index (BMI) calculation is based on height and weight. A BMI of 25–30 is considered overweight,

and a BMI over 30 is considered obese. 3 Safety-sensitive positions are defined in FRA regulations at 49 CFR 209.303.

4 As part of a collective bargaining agreement, Metro-North train crew work assignments are re-opened for

seniority bid twice each year.

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adjustment to a dramatic shift in work schedule most likely resulted in him being fatigued at the

time of the accident.

Postaccident Actions

FRA Emergency Order 29 and Safety Advisory 2013-08

During the on-scene investigation, NTSB investigators determined that Metro-North

trains exceeding the prescribed speed limits were not uncommon. As a result, on

December 11, 2013, the FRA issued Emergency Order 29 which required Metro-North to take a

number of immediate steps to ensure trains were not operated at an excessive speed. The FRA

also issued Safety Advisory 2013-08 to all railroads on December 16, 2013, recommending that

the railroads emphasize speed compliance to the operating employees.

Metro-North Train-Speed Enforcement Program

As a result of information developed during the on-scene NTSB investigation,

Metro-North developed and implemented a train-speed enforcement program that involved radar

speed checks and increased reviews of event-recorder data to confirm that engineers were

adhering to speed limits.

FRA Safety Assessment of Metro-North

As a result of information obtained during this NTSB accident investigation and three

additional ongoing NTSB Metro-North investigations, the FRA assembled a team to conduct a

safety assessment of Metro-North operations. The FRA team interviewed Metro-North

personnel, inspected Metro-North equipment, and reviewed Metro-North compliance with

regulations. In March 2014, the FRA issued a report, Operation Deep Dive, Metro-North

Commuter Railroad Safety Assessment, that contained a number of recommendations for

improving safety on Metro-North. On May 15 2014, Metro-North submitted a response to the

FRA addressing the recommendations in the FRA safety assessment report.

NTSB Recommendations

On February 18, 2014, the NTSB issued safety recommendations to Metro-North

recommending the installation of permanent speed restriction signs, inward- and outward-facing

audio and image recorders, and the use of the recordings to verify crew compliance with safety

rules.5

5 For more information, see the NTSB letter, dated February 18, 2014, to Metro-North in which the NTSB

issued Safety Recommendations R-14-7 through -9. Safety Recommendation R-14-07 is classified

“Open―Unacceptable Response” and Safety Recommendations R-14-08 and -09 are classified “Open—Acceptable

Response.”

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Probable Cause

The National Transportation Safety Board determines that the probable cause of the

accident was the engineer’s noncompliance with the 30-mph speed restriction because he had

fallen asleep due to undiagnosed severe obstructive sleep apnea exacerbated by a recent

circadian rhythm shift required by his work schedule. Contributing to the accident was the

absence of a Metro-North Railroad policy or a Federal Railroad Administration regulation

requiring medical screening for sleep disorders. Also contributing to the accident was the

absence of a positive train control system that would have automatically applied the brakes to

enforce the speed restriction. Contributing to the severity of the accident was the loss of the

window glazing that resulted in the fatal ejection of four passengers from the train.

For more details about this accident, visit www.ntsb.gov/investigations/dms.html and

search for NTSB accident ID DCA14MR003. Adopted: October 24, 2014

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

CHRISTOPHER A. HART ROBERT L. SUMWALT Acting Chairman Member

MARK R. ROSEKIND Member

EARL F. WEENER

Member

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The NTSB has authority to investigate and establish the facts, circumstances, and cause or

probable cause of a railroad accident in which there is a fatality or substantial property damage, or

that involves a passenger train. (49 U.S. Code § 1131 - General authority)

The NTSB does not assign fault or blame for an accident or incident; rather, as specified by NTSB

regulation, “accident/incident investigations are fact-finding proceedings with no formal issues

and no adverse parties . . . and are not conducted for the purpose of determining the rights or

liabilities of any person.” 49 Code of Federal Regulations, Section 831.4. Assignment of fault or

legal liability is not relevant to the NTSB’s statutory mission to improve transportation safety by

investigating accidents and incidents and issuing safety recommendations. In addition, statutory

language prohibits the admission into evidence or use of any part of an NTSB report related to an

accident in a civil action for damages resulting from a matter mentioned in the report. 49 United

States Code, Section 1154(b).